The lecture has been given on Nov. 24th, 2010 by Dr. Sallama Kamil.

1. ‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬‫الرحيم‬ ‫الرحمن‬ ‫ال‬ ‫بسم‬
Endometriosis andEndometriosis and
AdenomyosisAdenomyosis
By Dr. Sallama KamelBy Dr. Sallama Kamel

2. Endometriosis is defined asEndometriosis is defined as::
Presence of endometrial tissues ( superficial epithelium,Presence of endometrial tissues ( superficial epithelium,
glands and stroma ) in places outside the uterine cavityglands and stroma ) in places outside the uterine cavity..
It is eitherIt is either::
11..External endometriosisExternal endometriosis::
The endometriotic tissues present outside the uterus (pelvisThe endometriotic tissues present outside the uterus (pelvis
and other placesand other places(.(.
22..Internal endometriosis (adenomyosisInternal endometriosis (adenomyosis(:(:
The presence of endometriotic tissues inside the uterineThe presence of endometriotic tissues inside the uterine
wall within the myometriumwall within the myometrium..

3. External EndometriosisExternal Endometriosis::
PrevalencePrevalence::
Endometriosis is a common and importantEndometriosis is a common and important
health problem of womenhealth problem of women..
It’s exact prevalence is unknown becauseIt’s exact prevalence is unknown because
surgery is required for diagnosissurgery is required for diagnosis..
It is estimated to be present in 3-10% ofIt is estimated to be present in 3-10% of
women in the reproductive age group and 25-women in the reproductive age group and 25-
35% of infertile women35% of infertile women..

4. PathogenesisPathogenesis::
The cause of endometriosis is unknownThe cause of endometriosis is unknown..
Many theories exit to explain the development ofMany theories exit to explain the development of
the disease but no single theory can explainthe disease but no single theory can explain
all sites of the diseaseall sites of the disease..
11..Menstrual regurgitation and implantationMenstrual regurgitation and implantation::
it has been suggested that endometriosisit has been suggested that endometriosis
resulted from retrograde menstrualresulted from retrograde menstrual
regurgitation of viable endometrial glands andregurgitation of viable endometrial glands and
tissue within the menstrual fluid andtissue within the menstrual fluid and
subsequent implantation on the peritonealsubsequent implantation on the peritoneal
surfacesurface..

5. The prove for this theory is the presence ofThe prove for this theory is the presence of
endometriosis in women with associatedendometriosis in women with associated
abnormalities of the genital tract , causingabnormalities of the genital tract , causing
obstruction of the vaginal outflow of menstrualobstruction of the vaginal outflow of menstrual
fluidfluid..
22..Coelomic epithelium transformationCoelomic epithelium transformation::
There is a common origin for the cells lining theThere is a common origin for the cells lining the
mullerian duct, the peritoneal cells and the cellsmullerian duct, the peritoneal cells and the cells
of the ovaryof the ovary..
It has been suggested that these cells undergoIt has been suggested that these cells undergo
de-differentiation back to their primitive originde-differentiation back to their primitive origin
and then transform into endometrial cellsand then transform into endometrial cells..
This transformation into endometrial cells mayThis transformation into endometrial cells may
be due to hormonal stimuli of ovarian originbe due to hormonal stimuli of ovarian origin

6. 33..Vascular and lymphatic spreadVascular and lymphatic spread::
Vascular and lymphatic embolization ofVascular and lymphatic embolization of
endometrial cells to distant organs hasendometrial cells to distant organs has
been demonstrated and explain the rarebeen demonstrated and explain the rare
finding of endometriosis in sites outsidefinding of endometriosis in sites outside
the peritoneal cavitythe peritoneal cavity..
This will explain foci in the kidneys,This will explain foci in the kidneys,
joints, skin and lungjoints, skin and lung..

7. 44..Genetic and immunological factorsGenetic and immunological factors::
It has been suggested that genetic andIt has been suggested that genetic and
immunological factors may alterimmunological factors may alter
susceptibility of a woman and allow hersusceptibility of a woman and allow her
to develop endometriosisto develop endometriosis..
There appear to be an increasedThere appear to be an increased
incidence in the 1incidence in the 1stst
degree relatives ofdegree relatives of
patients with the disorderpatients with the disorder..
Also there is racial difference withAlso there is racial difference with
increased incidence amongst orientalincreased incidence amongst oriental
women and low prevalence in patients ofwomen and low prevalence in patients of
Afro-Caribbean originAfro-Caribbean origin..

8. 55..The role of the immune systemThe role of the immune system::
The activity of peritoneal natural killerThe activity of peritoneal natural killer
and T-lymphocytes is suppressed inand T-lymphocytes is suppressed in
women with endometriosis , but whetherwomen with endometriosis , but whether
these immunologic deviations are thethese immunologic deviations are the
cause or the result of endometriosis iscause or the result of endometriosis is
still unclearstill unclear..
Endometriosis may occur when aEndometriosis may occur when a
deficiency in cellular immunity allowsdeficiency in cellular immunity allows
menstrual tissue to implant and grow onmenstrual tissue to implant and grow on
the peritoneumthe peritoneum..

9. PathologyPathology::
The gross appearance of endometriosisThe gross appearance of endometriosis
is quite characteristicis quite characteristic..
The smallest and earliest implants areThe smallest and earliest implants are
red, petechial lesions on the peritonealred, petechial lesions on the peritoneal
surfacesurface..
With further growth, menstrual- likeWith further growth, menstrual- like
detritus accumulates within the lesiondetritus accumulates within the lesion
giving it agiving it a cystic, dark brown, dark blue,cystic, dark brown, dark blue,
or black appearance (burned drum-stickor black appearance (burned drum-stick
appearanceappearance..

11. Ovarian endometriosisOvarian endometriosis

12. The surrounding peritoneal surfaceThe surrounding peritoneal surface
becomes thickened and scarredbecomes thickened and scarred..
These powder burn implants typicallyThese powder burn implants typically
attain a size of 5-1o mm in diameterattain a size of 5-1o mm in diameter..
With progression of the diseaseWith progression of the disease,,
thethe number and size of the lesion increasenumber and size of the lesion increase
and extensive adhesions developand extensive adhesions develop..
On the ovary, the cysts enlarge toOn the ovary, the cysts enlarge to
several centimeters in size and areseveral centimeters in size and are
calledcalled endometriomas or chocolate cystsendometriomas or chocolate cysts..

13. The most common sites of the diseaseThe most common sites of the disease
areare::
11..TheThe oovariesvaries (approximately half of the cases)(approximately half of the cases)
which of two typeswhich of two types superficialsuperficial small lesions andsmall lesions and
these lesions with time will go deep in the ovarythese lesions with time will go deep in the ovary
and coalesces together forming single bigand coalesces together forming single big
cyst(deep lesioncyst(deep lesion(.(.
22..Then the uterine cul-de-sac (Pouch of DouglasThen the uterine cul-de-sac (Pouch of Douglas(.(.
33..Uterosacral ligamentsUterosacral ligaments..
44..The posterior surface of the uterus and broadThe posterior surface of the uterus and broad
ligamentsligaments..
The remaining pelvic peritoneumThe remaining pelvic peritoneum..

14. OTHER SITES AREOTHER SITES ARE::
55..Implants may occur over the bowel, bladder, andImplants may occur over the bowel, bladder, and
uretersureters..
rarely they may erode into underlying tissue andrarely they may erode into underlying tissue and
cause blood in stool or urinecause blood in stool or urine..
Or the associated adhesions may results inOr the associated adhesions may results in
stricture and obstruction of these organsstricture and obstruction of these organs..
66..Implants may occur on the cervix, posteriorImplants may occur on the cervix, posterior
vaginal fornixvaginal fornix..
77..Also within wounds contaminated by endometrialAlso within wounds contaminated by endometrial
tissue e.g. scar of C/S or episiotomytissue e.g. scar of C/S or episiotomy..
88..Very rarely lesions may found in the lung, brain,Very rarely lesions may found in the lung, brain,
and kidneysand kidneys..

15. Clinical features:
Clinical findings vary greatly depending onClinical findings vary greatly depending on
the number, size and extent of the lesionthe number, size and extent of the lesion..
The main presenting symptoms areThe main presenting symptoms are::
--InfertilityInfertility..
--Dysmenorrhoea usually congestive typeDysmenorrhoea usually congestive type..
--Dyspareunia (usually deep DyspareuniaDyspareunia (usually deep Dyspareunia(.(.
--Most patients complain of constant pelvicMost patients complain of constant pelvic
pain or a low sacral backache that occurpain or a low sacral backache that occur
premenstruallypremenstrually..
There may cycle abnormalities likeThere may cycle abnormalities like
menorrhagia or polymenorrheamenorrhagia or polymenorrhea

16. --Lesions on or near the external surface of theLesions on or near the external surface of the
cervix, vagina, vulva urethra and rectum maycervix, vagina, vulva urethra and rectum may
cause pain or bleeding with defecation, urinationcause pain or bleeding with defecation, urination
or coitus at any time in the menstrual cycleor coitus at any time in the menstrual cycle
--Other symptoms are related to the site of theOther symptoms are related to the site of the
lesionlesion..
Lesions in the urinary tractLesions in the urinary tract cause cyclical dysuriacause cyclical dysuria
and haematuriaand haematuria..
--In Gastrointestinal tractIn Gastrointestinal tract cause dyschezia, cyclicalcause dyschezia, cyclical
rectal bleeding and obstructionrectal bleeding and obstruction..
--in the Lungin the Lung cause cyclical haemoptysis andcause cyclical haemoptysis and
haemopneumothoraxhaemopneumothorax..
--In the umbilicus and surgical scarsIn the umbilicus and surgical scars : cyclical pain: cyclical pain
and bleedingand bleeding..

17. The occurrence of abnormalThe occurrence of abnormal
cyclical bleeding at the time ofcyclical bleeding at the time of
menstruation from the rectum ,menstruation from the rectum ,
bladder or umbilicusbladder or umbilicus is pathognomicis pathognomic
of the diseaseof the disease..

18. The physical examination classically revealsThe physical examination classically reveals::
••Tender nodules in the posterior vaginal fornixTender nodules in the posterior vaginal fornix..
••Pain upon uterine motionPain upon uterine motion..
••The uterus may be fixed and retroverted due toThe uterus may be fixed and retroverted due to
cul-de-sac adhesionscul-de-sac adhesions..
••Tender adnexial masses may be felt due to theTender adnexial masses may be felt due to the
presence of endometriomaspresence of endometriomas..
••Careful inspection may reveals implants inCareful inspection may reveals implants in
healed wounds especially episiotomy andhealed wounds especially episiotomy and
caesarian section incisions, in the vaginalcaesarian section incisions, in the vaginal
fornix or on the cervixfornix or on the cervix..
••Many patients are asymptomatic and have noMany patients are asymptomatic and have no
abnormal findings on examinationabnormal findings on examination..

19. DiagnosDiagnosisis
The diagnosis of endometriosis can beThe diagnosis of endometriosis can be
suggested by the clinical findingssuggested by the clinical findings
mentioned abovementioned above..
However aHowever a specific diagnosis requiresspecific diagnosis requires
visualization and in uncertain cases,visualization and in uncertain cases,
biopsy of lesions, either at laparoscopy orbiopsy of lesions, either at laparoscopy or
laparotomylaparotomy..

20. LaparoscopyLaparoscopy::
Laparoscopy remain the gold standard means ofLaparoscopy remain the gold standard means of
diagnosing this condition. Itdiagnosing this condition. It provideprovide::
11..direct visualization of endometriotic lesionsdirect visualization of endometriotic lesions..
22..To take biopsy from suspected areasTo take biopsy from suspected areas..
33..Allows staging of the disease depending on theAllows staging of the disease depending on the
extent of adhesionsextent of adhesions and theand the numbernumber andand size ofsize of
lesionslesions..
44..Also allows concurrent therapy in the form ofAlso allows concurrent therapy in the form of
cautery or laser treatment in selected casescautery or laser treatment in selected cases..
--Ultrasound , CT-scan and MRI have little value inUltrasound , CT-scan and MRI have little value in
the diagnosis of endometriosisthe diagnosis of endometriosis..

21. Staging of the diseaseStaging of the disease::
Endometriosis is classified intoEndometriosis is classified into mild ,mild ,
moderate, sever and extensivemoderate, sever and extensive using theusing the
American Fertility SocietyAmerican Fertility Society’’s scorings scoring
systemsystem which depend on thewhich depend on the
11..Extent of the lesions (number and sizeExtent of the lesions (number and size(.(.
22..Associated adhesions in the peritoneumAssociated adhesions in the peritoneum..

23. Endometriosis and infertilityEndometriosis and infertility::
••It is estimated that 30-40% of patients with endometriosis haveIt is estimated that 30-40% of patients with endometriosis have
difficulty in conceivingdifficulty in conceiving..
••In the sever disease there is usually anatomical distortion with peri-In the sever disease there is usually anatomical distortion with peri-
adnexial adhesions and destruction of ovarian tissues whenadnexial adhesions and destruction of ovarian tissues when
endometriomas developendometriomas develop..
••But with mild disease it is still unclear why it cause infertilityBut with mild disease it is still unclear why it cause infertility..
Numerous mechanisms have been proposed, including
abnormal folliculogenesis, anovulation, luteal insufficiency,
luteinized unruptured follicle syndrome, recurrent miscarriage,
decreased sperm survival, altered immunity, intraperitoneal
inflammation and endometrial dysfunction.
-However, all these functional disturbances can occur in subfertile
women without endometriosis,
-which suggests that finding disease during investigation
for subfertility may be coincidental.

24. TreatmentTreatment::
Treatment options are dictated byTreatment options are dictated by
••The patientThe patient’’s symptomss symptoms..
••Her ageHer age..
••The stage of her diseaseThe stage of her disease..
••Her desire for future fertilityHer desire for future fertility..
The aim of the treatment areThe aim of the treatment are::
••To relieve painTo relieve pain..
••Allows satisfactory coitusAllows satisfactory coitus..
••Improves the patient’s fertility if possibleImproves the patient’s fertility if possible..

25. TreatmentTreatment modalities availablemodalities available::
Medical treatmentMedical treatment::
11..NSAIDNSAID..
22..Oral contraceptive pillsOral contraceptive pills..
33..Progestational agentsProgestational agents..
44..Danazol and GestrinoneDanazol and Gestrinone..
55..LHRH- analogue (GnRH agonistLHRH- analogue (GnRH agonist(.(.
Surgical treatmentSurgical treatment::
11..Conservative (by laparoscopy or laparotomyConservative (by laparoscopy or laparotomy((
22..Radical surgeryRadical surgery..

26. Medical treatmentMedical treatment::
11..Analgesic therapyAnalgesic therapy::
••Non-steroidal anti-inflammatory drugs areNon-steroidal anti-inflammatory drugs are
potent analgesicspotent analgesics..
••They are helpful in reducing the severityThey are helpful in reducing the severity
of dysmenorrhoeaof dysmenorrhoea..
••It has no effect on the disease and itIt has no effect on the disease and it ’’ss
progressionprogression..
••So their use is as adjunctive treatmentSo their use is as adjunctive treatment
onlyonly..

27. 22..Hormonal therapyHormonal therapy::
The aim of treatment with hormonal therapy is to interruptThe aim of treatment with hormonal therapy is to interrupt
the cycles of stimulation and bleeding of endometrioticthe cycles of stimulation and bleeding of endometriotic
tissue by giving drugs that suppress the ovarian cycle.tissue by giving drugs that suppress the ovarian cycle.
This can be achieved with various agentsThis can be achieved with various agents..
11..Oral contraceptive pillsOral contraceptive pills::
••This is prescribed as 1This is prescribed as 1 pill a day for 6-12 monthspill a day for 6-12 months..
••The continuous exposure to combined oral contraceptiveThe continuous exposure to combined oral contraceptive
pills results in decidual changes in the endometrialpills results in decidual changes in the endometrial
glandsglands..
••Rate of pregnancy following discontinuation of therapy canRate of pregnancy following discontinuation of therapy can
be as high as 50%be as high as 50%..
The patient may have break through bleeding, weight gain,The patient may have break through bleeding, weight gain,
headache, nausea, mood changesheadache, nausea, mood changes..

28. Progestational agentsProgestational agents::
These agents cause decidualization in theThese agents cause decidualization in the
endometriotic tissueendometriotic tissue..
••Oral medroxyprogesterone acetateOral medroxyprogesterone acetate can becan be
prescribed as a 10-30mg dailyprescribed as a 10-30mg daily..
••Depot medroxyprogesterone acetateDepot medroxyprogesterone acetate
150mg i.m can be given as a single dose150mg i.m can be given as a single dose
every 3 monthsevery 3 months..
••Side effectsSide effects::
••Irritability, depression, breakthroughIrritability, depression, breakthrough
bleeding, and bloatingbleeding, and bloating..

29. DanazolDanazol::
••Danazol is a weak androgenDanazol is a weak androgen..
••Danazol acts via several mechanisms to treat endometriosis byDanazol acts via several mechanisms to treat endometriosis by
ofof||causing amenorrhea and atrophycausing amenorrhea and atrophy
The dosage of Danazol isThe dosage of Danazol is 400-800mg/day400-800mg/day in divided doses forin divided doses for
6months6months..
Side effectsSide effects::
••AcneAcne..
••Oily skinOily skin..
••Deepening of the voiceDeepening of the voice..
••Weight gainWeight gain..
••EdemaEdema..
••Adverse plasma lipoprotein changesAdverse plasma lipoprotein changes..
••Most changes are reversible upon cessation of therapyMost changes are reversible upon cessation of therapy..
GestrinoneGestrinone inhibit LH &FSH secretion in a dose of 2.5mg twiceinhibit LH &FSH secretion in a dose of 2.5mg twice
weekly with similar side effects of Danazolweekly with similar side effects of Danazol..

30. Gonadotropin- releasing hormone agonistsGonadotropin- releasing hormone agonists
(GnRH agonist(GnRH agonist(.(.
**These agents are analogues of GnRHThese agents are analogues of GnRH..
**When given continuously causeWhen given continuously cause
suppression of gonadotropin secretionsuppression of gonadotropin secretion..
**So suppress ovarian cycle andSo suppress ovarian cycle and
endometrial implantsendometrial implants..
GnRH agonists can be administeredGnRH agonists can be administered
••intramuscularlyintramuscularly e.g. leuprolide acetatee.g. leuprolide acetate
3.75mg once a month3.75mg once a month..
••IntranasalyIntranasaly as nafarelin 200mg twiceas nafarelin 200mg twice
dailydaily..
••subcutaneouslysubcutaneously as goserlin 3.75 mg onceas goserlin 3.75 mg once
a montha month..

31. These agents are used for 6 months because ofThese agents are used for 6 months because of
their side effects related to the hypo-estrogenictheir side effects related to the hypo-estrogenic
state includingstate including::
••Lose of bone mineral density (the most importantLose of bone mineral density (the most important
one causing osteoporosisone causing osteoporosis(.(.
••Vasomotor symptomsVasomotor symptoms..
••Vaginal drynessVaginal dryness..
••Mood changesMood changes..
Now a days they start to add low dose estrogenNow a days they start to add low dose estrogen
e.g.0.625 mg of conjugated equine estrogen toe.g.0.625 mg of conjugated equine estrogen to
relieve the side effects of these drugsrelieve the side effects of these drugs
especially the bone loseespecially the bone lose..

32. Surgical treatmentSurgical treatment::
11..Conservative surgical treatmentConservative surgical treatment::
This is indicated for women withThis is indicated for women with infertility, whoinfertility, who
have sever disease and symptoms withhave sever disease and symptoms with
adhesionsadhesions..
By surgery we shouldBy surgery we should::
••excise or destroy all endometriotic tissuesexcise or destroy all endometriotic tissues
••Remove all adhesions (adhesolysisRemove all adhesions (adhesolysis(.(.
••Restore pelvic anatomy to the best possibleRestore pelvic anatomy to the best possible
conditioncondition..
••Tubal surgeryTubal surgery..
••Pre-sacral neurectomy or Uterosacral ligamentsPre-sacral neurectomy or Uterosacral ligaments
ablation to relieve painablation to relieve pain..
••Uterine suspension also done if requiredUterine suspension also done if required..
..

33. ••All these procedures can be performed byAll these procedures can be performed by
laparoscopy or laparotomylaparoscopy or laparotomy..
••For women with infertility who failedFor women with infertility who failed
all other therapy can undergoesall other therapy can undergoes
assisted reproduction (in vitroassisted reproduction (in vitro
fertilizationfertilization(.(.

34. Definitive surgeryDefinitive surgery::
For patient withFor patient with severe disease or symptoms,severe disease or symptoms,
who does not desire further pregnancywho does not desire further pregnancy..
This includesThis includes total abdominal hysterectomy andtotal abdominal hysterectomy and
bilateral salpingo-oophorectomy with excisionbilateral salpingo-oophorectomy with excision
of the remaining adhesions or implantsof the remaining adhesions or implants..
Post-operative medical therapy may bePost-operative medical therapy may be
indicated in some patients to get rid of allindicated in some patients to get rid of all
remaining implantsremaining implants..
Women who undergo definitive surgery can beWomen who undergo definitive surgery can be
given hormone replacement therapy with outgiven hormone replacement therapy with out
reactivation of endometriotic tissuesreactivation of endometriotic tissues..

35. AdenomyosisAdenomyosis::
Means the presence ofMeans the presence of endometrial glands and stromaendometrial glands and stroma
deep within the myometriumdeep within the myometrium..
--It has a different etiology than endometriosisIt has a different etiology than endometriosis..
--The exact etiology is unknown but it has been suggested toThe exact etiology is unknown but it has been suggested to
be related tobe related to weakness of the myometrial smooth muscleweakness of the myometrial smooth muscle
from repeated pregnancies, or trauma induced byfrom repeated pregnancies, or trauma induced by
surgerysurgery..
The incidence of this condition is more inThe incidence of this condition is more in::
11..Multiparous women in their late thirties or early forties ofMultiparous women in their late thirties or early forties of
ageage..
22..Women who has previous curettage or induced abortionWomen who has previous curettage or induced abortion..
33..More common in women having endometrial hyperplasiaMore common in women having endometrial hyperplasia
and fibroidsand fibroids..
clinically the patientclinically the patient presented with increasinglypresented with increasingly severesevere
secondary dysmenorrhoea and menorrhagiasecondary dysmenorrhoea and menorrhagia..
The uterus is bulky and tender particularly if examinedThe uterus is bulky and tender particularly if examined
perimenstruallyperimenstrually..

36. DiagnosisDiagnosis::
 Clinical features are non specificClinical features are non specific..
Transvaginal ultrasound may show alteration ofTransvaginal ultrasound may show alteration of
echogenicity within the myometrium from the localizedechogenicity within the myometrium from the localized
distended endometrial glands. some times thedistended endometrial glands. some times the
appearance may resemble uterine fibroidappearance may resemble uterine fibroid..
MRI may be more specific than ultrasound in theMRI may be more specific than ultrasound in the
diagnosisdiagnosis..
However specific diagnosis for suspected cases is onlyHowever specific diagnosis for suspected cases is only
obtainedobtained by pathological examination of the hysterectomyby pathological examination of the hysterectomy
specimen performed for symptomatic reasonsspecimen performed for symptomatic reasons..

37. TreatmentTreatment::
••Drugs that induce amenorrhoea areDrugs that induce amenorrhoea are
helpful since they relieve pain andhelpful since they relieve pain and
excessive bleeding (Danazol, Gestrinoneexcessive bleeding (Danazol, Gestrinone
and GnRH agonist can be usedand GnRH agonist can be used(.(.
••However on stopping the treatmentHowever on stopping the treatment
symptoms return rapidly in the majoritysymptoms return rapidly in the majority
of patientsof patients..
So hysterectomy is the only definitiveSo hysterectomy is the only definitive
treatment availabletreatment available..

38. Thank youThank you